Block 3 Flashcards
Inspection of the left ventricle reveals all except which of the following?
Papillary muscles
Trabeculae carnae
Chordae tendinae
Conus arteriosus
Openings of the venae cordis minimae
The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.
A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?
Intercostal vein
Intercostal artery
Parietal pleura
Visceral pleura
None of the above
The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathetomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access
A 44 year old man undergoes a distal gastrectomy for cancer. He is slightly anaemic and therefore receives a transfusion of 4 units of packed red cells to cover both the existing anaemia and associated perioperative blood loss. He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?
Hyponatraemia
Hyperkalaemia
Hypercalcaemia
Metabolic alkalosis
Hypernatraemia
The transfusion of packed red cells has been shown to increase serum potassium levels. The risk is higher with large volume transfusions and with old blood.
Treatment of hyperhidrosis possible complications
For treatment of hyperhidrosis the sympathetic denervation can be achieved by removing the second and third thoracic ganglia with their rami. Removal of T1 will cause a Horners syndrome and is therefore not performed.
In which space is a lumbar puncture performed?
Subdural space
Epidural space
Subarachnoid space
Extradural space
Intraventricular space
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture.
A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of 50. She is due to undergo a splenectomy. What is the optimal timing of a platelet transfusion in this case?
24 hours pre-operatively
2 hours pre-operatively
Whilst making the skin incision
After ligation of the splenic artery
On removal of the spleen
ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should be carefully timed. Too soon and it will be ineffective. Too late and unnecessary bleeding will occur. The optimal time is after the splenic artery has been ligated.
Indications for splenectomy
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses
Post-splencetomy changes
Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given.
Epidemiology of colonoscopy
5 out of 10 will have a normal exam
4 out of 10 will have polyps
1 out of 10 will have cancer
What patients need referral for colonoscopy
- Altered bowel habit for more than six weeks
- New onset of rectal bleeding
- Symptoms of tenesmus
A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
Radial
Recurrent branch of median
Anterior interosseous
Ulnar
Median
Median
Most common primary liver tumours
Cholangiocarcinoma and HCC.
Metastatic disease accounts for 95% of all liver malignancies
Diagnosis of HCC
CT/MRI
AFP
Biopsy should be avoided as it seeds tumour cells.
In diagnostic uncertainty, serial CT and aFP measurents are prefered
Staging of HCC
Liver MRI, CT CAP
Use of PET CT in HCC
Can be used to identify occult nodal disease
Treatment of HCC
Surgical resection is the mainstay of treatment in operable cases. In patients with a small primary tumour in a cirrhotic liver whose primary disease process is controlled, consideration may be given to primary whole liver resection and transplantation.
Liver resections are an option but since most cases occur in an already diseased liver the operative risks and post-operative hepatic dysfunction are far greater than is seen following metastectomy.
These tumours are not particularly chemo or radiosensitive however, both may be used in a palliative setting. Tumour ablation is a more popular strategy.
Survival in HCC
15% at 5 years
Tumour markers in cholangiocarcinoma
CA 19-9, CEA and CA 125 are often elevated
Diagnosis of cholangiocarcinoma
Patients will typically have an obstructive picture on liver function tests.
CA 19-9, CEA and CA 125 are often elevated
CT/ MRI and MRCP are the imaging methods of choice.
Treatment of cholangiocarcinoma
Surgical resection offers the best chance of cure. Local invasion of peri hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection.
Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection.
Survival in cholangiocarcinoma
5-10% 5ys
A 56 year old man has long standing chronic pancreatitis and develops pancreatic insufficiency. Which of the following will be absorbed normally?
Fat
Protein
Folic acid
Vitamin B12
None of the above
Pancreatic lipase is required for digestion of fat, Proteases facilitate protein and B12 absorption. Folate digestion is independent of the pancreas.
Rate of pancreatic secretions
1000-1500mL per 24 hours
pH 8
Substances secreted by acinar cells of the pancreas
Trypsinogen
Procarboxylase
Amylase
Elastase

































